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Complementary and Alternative Therapy Usage Status and Attitudes of Hypertension Patients
Hipertansiyon Hastalarının Tamamlayıcı ve Alternatif Tedavi Kullanım Durumlarının ve Tutumlarının İncelenmesi
Hilal Gökçe, Eylem Paslı Gürdoğan

Euras J Fam Med 2019;8(2):59-68. https://doi.org/10.33880/ejfm.2019080202

 

Original Research / Orijinal Araştırma


ABSTRACT

Aim: With the increase in chronic diseases, the number of patients using complementary and alternative medicine is increasing. In this study, it was aimed to examine the opinions and practices of complementary and alternative therapy usage status and attitudes of hypertension patients.

Methods: A descriptive and cross-sectional study consisting of 290 patients was performed with patients who applied to the cardiology and internal diseases outpatient clinic of a public hospital and diagnosed with hypertension. Data were collected by using the patient information form which including socio-demographic form, disease-related characteristics and opinions, and also practices of the patients about the use of complementary and alternative therapies and attitudes towards Holistic Complementary and Alternative Medicine Scale.

Results: The mean age of the patients was 61.52±11.19 and 63.1% were female, 83.4% were married, and 74.8% were at primary school and lower education level. Of patients, 56.9% use complementary and alternative treatment methods in addition to hypertension therapy. 27.3% of them think that they are more effective than drugs, 63% of them do not share the method they use with health care workers. The total score of the Holistic Complementary and Alternative Medicine Scale is 23.05±5.80. The scores are taken out of the scale and the sub-dimensions differ according to the age groups, education level, monthly income status and complementary and alternative treatment methods usage status (p <0.05).

Conclusion: It was found that patients use complementary and alternative methods but do not share them with health care workers, and they have a positive attitude towards holistic complementary and alternative medicine. It is considered important for health care professionals to question the use of these methods in planning the patients’ treatment.

Keywords: complementary medicine, alternative medicine, hypertension, patients, attitude

ÖZ

Amaç: Kronik hastalıkların artmasıyla birlikte tamamlayıcı alternatif tedavi kullananların sayısı da artmaktadır. Bu çalışmada, hipertansif hastaların tamamlayıcı alternatif tedavilerin kullanımına yönelik görüş ve uygulamaları ile bu tedavilere olan tutumlarının incelenmesi amaçlanmıştır. 

Yöntem: Tanımlayıcı ve kesitsel tipteki araştırma bir devlet hastanesinin kardiyoloji ve iç hastalıkları polikliniklerine başvuran hipertansiyon tanısı konulmuş olan 290 hasta ile yapıldı. Veriler, hastaların sosyo-demografik özellikleri, hastalığa ilişkin özellikleri ve tamamlayıcı alternatif tedavi kullanımına ilişkin görüş ve uygulamalarını içeren “Hasta Bilgi Formu” ve “Bütüncül Tamamlayıcı ve Alternatif Tıbba Karşı Tutum Ölçeği” kullanılarak toplandı.

Bulgular: Hastaların yaş ortalaması 61,52±11,19 olup, %63,1’i kadın, %83,4’’ü evli, %74,8’i ilköğretim ve altı eğitim düzeyindedir. Hastaların %56,9’u hipertansiyon tedavisine ek olarak tamamlayıcı ve alternatif tedavi yöntemlerini kullanmakta, %27,3’ü ilaçlardan daha etkili olduğunu düşünmekte, %63’ü kullandıkları yöntemi sağlık çalışanları ile paylaşmamaktadır. Hastaların Bütüncül Tamamlayıcı ve Alternatif Tıbba Karşı Tutum Ölçeği toplam puanı 23,05±5,80’dir. Ölçek ve alt boyutlarından alınan puanlar hastaların yaş gruplarına, eğitim düzeyine, aylık gelir durumuna ve Tamamlayıcı ve Alternatif Tıp kullanma durumlarına göre farklılık göstermektedir (p<0.05). 

Sonuç: Hastaların Tamamlayıcı ve Alternatif Tıp yöntemlerini kullandıkları ancak sağlık çalışanları ile paylaşmadıkları ve Tamamlayıcı ve Alternatif Tıp yöntemlerine karşı olumlu tutuma sahip oldukları bulundu. Sağlık çalışanlarının hastaların bu yöntemleri kullanım durumlarını sorgulamalarının tedaviyi planlamada önemli olduğu düşünülmektedir. 

Anahtar kelimeler: tamamlayıcı tıp, alternatif tıp, hipertansiyon, hastalar, tutum


Introduction

Hypertension is one of the most important health problems at the global level and it is a preventable and treatable disease. Despite the positive developments in the treatment, the number of hypertensive patients is rapidly increasing due to the increase in the elderly population; in addition to poor awareness of patients, poor compliance with treatment, and the increase in the incidence in low- and middle-income countries (1). In a study that investigated the change in the prevalence of hypertension in the last 40 years, it was found that the number of hypertensive individuals exceeded one billion people in the world by 2015 and increased by 90% (2). The incidence of hypertension is reported to be 29.9% in Turkey, 33% in the United States and 30-45% in Europe (1,3,4).

Hypertension is a chronic disease that can be controlled by medical treatment as well as lifestyle changes.Besides the compliance with the suggested treatment, lifestyle changes have an important place in the blood pressure control of individuals (5,6). In parallel with the increase in the prevalence of hypertension, there is an increasing interest in complementary and alternative therapies (CAM) in hypertensive individuals (5,7). It has been reported in the literature that the frequency of CAM use in patients with hypertension varies between 12.8% and 85.7% (8).

The complementary therapies include methods which are used by patients in addition to modern medicine, while alternative therapies include methods that replace modern medical practices and are not scientifically proven (9,10). Today, the most important reason for patients to approach CAM is the side effects that are believed to appear due to the drug treatment used and the doubt that the treatment will be inadequate. Moreover, the increase in chronic diseases in parallel with the increasing life expectancy, the frequency of CAM usage increases because of the difficulties experienced in reaching new treatment methods and the high cost of these treatments, and the dissatisfaction with the time allocated by the health care workers to patients (9,11-13).

While the use of complementary and alternative therapies are increasing, it is reported that the patients do not receive counseling from health care professionals about the methods they use and their knowledge about CAM is limited to what they hear mostly from media and other individuals who are not health care workers (5,7,14). However, unconscious use of CAM methods can reduce the efficacy of drug therapy and may lead to undesirable drug interactions and side effects, as well as prolongation of the treatment process or organ dysfunctions (15). For this reason, it is important for health care workers to question the patients' CAM usage status, the methods they use and the reasons for their use in order to prevent complications that may develop in patients diagnosed with hypertension and to control blood pressure successfully.

The aim of this study is to investigate the opinions and practices of hypertensive patients on the use of complementary and alternative therapies and their attitudes towards holistic complementary and alternative medicine.

Methods

This descriptive and cross-sectional study was carried out in the cardiology and internal diseases outpatient clinics of a state hospital. The sample of the study consisted of 290 patients who were admitted to the outpatient clinics between January and July 2017, were diagnosed with hypertension at least 6 months ago and used antihypertensive drugs and volunteered to participate in the study. 

The study was approved by Trakya University Medical Faculty Ethics Committee (Protocol no: 2016/279). Before the data were collected, the purpose of the study was explained to the patients and their informed consent was obtained. The patients were informed that the data would be kept confidential and would be used only for scientific purposes and that they could disclaim to fill out the questionnaire if they feel uncomfortable with the questions.

The data of the study were collected by using Patient Information Form which includes the socio-demographic characteristics of the patients, characteristics of the disease, and patients opinions and practices related to the use of complementary and alternative therapy and attitudes towards Holistic Complementary and Alternative Medicine (HCAM) Scale.

Attitudes toward Holistic Complementary and Alternative Medicine (HCAM) Scale:

The scale was developed by Hyland et al. (16). The Turkish validity and reliability analysis of the scale was conducted by Erci (17). The scale consists of 11 items and it is in a six-point Likert scale type (strongly agree = 1, agree = 2, partly agree = 3, partly disagree = 4, disagree = 5, strongly disagree = 6). There are two sub-dimensions of the scale. The holistic health sub-dimension assesses the patient's perception of individuality in his/her care, and the complementary and alternative medicine sub-dimension evaluates the patient's attitudes towards the use of complementary and alternative therapy. The lowest possible score is 11, and the highest possible score is 66. The low score obtained from the scale indicates a positive attitude towards complementary and alternative medicine, and a high score indicates a negative attitude towards complementary and alternative medicine. In the study of Erci, cronbach’s alpha value of the scale was found to be 0.72 (17). In this study, cronbach’s alpha value was found to be 0.78.

The data were evaluated by using the IBM SPSS (Statistical Package for the Social Sciences for Windows 22.0) package program. In addition to the descriptive statistical methods, Mann-Whitney U test was used to compare quantitative continuous data between two independent groups that did not show normal distribution, and Kruskall-Wallis test was used to compare quantitative continuous data between more than two independent groups. Statistical significance was accepted as p <0.05.

Results

The mean age of the patients (n=290) was 61.52 ± 11.19 years, and the ages ranged from 27 to 82, 63.1% were women, 83.4% were married and 74.8% were at primary education level or below, 53.1% had monthly income equal to the monthly outcome. It was determined that 45.5% of the patients had a diagnosis of hypertension 1 to 5 years ago, 64.5% used a single antihypertensive drug, 47.9% had additional chronic disease/diseases, and 70% had a family history of hypertension (Table 1).

Table 1. Characteristics of patients (n = 290)

Characteristics

n

%

Age (Mean±SD=61,52±11,19) 

50 years old and below

51-60 years old

61-70 years old

70 years old and above

 

48

84

97

61

 

16.6

29.0

33.4

21.0

Gender

Female

Male

 

183

107

 

63.1

36.9

Marital Status

Married

Single

 

242

48

 

83.4

16.6

Education Level

Primary School and below

High School and above

 

217

73

 

74.8

25.2

Monthly Income

Income equals outcome

Income less than outcome

Income more than outcome

 

154

79

57

 

53.1

27.2

19.7

HT diagnosis

1-5 years

6-10 years

11-15 years

16-20 years

20 years and above

 

132

86

27

33

12

 

45.5

29.7

9.3

11.4

4.1

Number of drugs used for HT treatment

One 

Two

Three

 


187

96

7

 


64.5

33.1

2.4

Additional chronic diseases

Yes

No

 

139

151

 

47.9

52.1

HT family history

Yes

No

 

203

87

 

70

30

HT: Hypertension

 

When we look at the opinions and practices of CAM using patients, it was determined that 80% of them know about CAM methods used in hypertension, and 59% of these patients heard these methods from other individuals around them who were not health care personnel. It was found that 64.8% of patients thought that CAM methods were beneficial, 56.9% used CAM, 43% used CAM twice a week, 27.3% thought that CAM was more effective than drugs. Patients using CAM (n=165) mostly used lemon (80.6%) and garlic (41.2%), and 63% did not share the method they used with the health care workers. The reasons for not sharing were the thinking that they do not need to (41.1%) and that the health care worker would react/get angry (39.4%) (Table 2). 

 

Table 2. Opinions and practices of patients on CAM use (n = 290)

Opinions and practices

n

%

Knowledge of the CAM methods used in HT

Yes

No

 

232

58

 

80

20

Where TAT methods are heard from* 

Media / Internet

People around

Health care personnel

No knowledge

 

97

171

30

58

 

33.4

59.0

10.3

20

Considering the CAM methods as useful

Yes

No

I do not have any idea.

 

188

40

62

 

64.8

13.8

21.4

Actively using CAM in the treatment of HT

Yes

No

 

165

125

 

56.9

43.1

CAM methods used* (n=165)**

Lemon

Garlic

Parsley

Olive oil

Cherry stem

Quince leaf

Green tea

Corn tassel

Flaxseed oil

 

133

68

22

13

8

8

3

3

1

 

80.6

41.2

13.3

7.9

4.8

4.8

1.8

1.8

0.6

Frequency of weekly CAM use (n=165)**

Once in a week

Twice a week

Three times a week

Four times a week and above

 

48

71

30

16

 

29.1

43

18.2

9.7

Reason for using CAM (n=165)**

Balancing blood pressure

Friend recommendation

CAM is more effective than drugs

A cheaper method than drugs

Side effects are less than drugs

Supplementary to medical treatment

 

19

27

45

16

33

25

 

11.5

16.4

27.3

9.7

20

15.1

Sharing the CAM method used with the health care worker (n=165)**

Yes

No

 

61

104

 

37.0

63.0

The reason for not sharing the CAM method used with the health care worker (n=104)***

No need

The thought of reaction

No reason in mind

 

 

49

41

14

 

 

47.1

39.4

13.5

HT: Hypertension CAM: Complementary and Alternative Therapy. *More than one option is marked. **Calculated based on CAM method users. ***Calculated based on those who do not share with health care workers.

 

The HCAM total score was 23.05 ± 5.80 (min = 12, max = 42), the holistic health sub-dimension score was 7.36 ± 1.68 (min = 5, max = 13) and the CAM sub-dimension score was 15.69 ± 5.52 (min = 6, max = 34) (Table 3).

 

Table 3.The mean scores of HCAM Scale of the patients (n = 290)

Scale and Sub-dimensions

Number of items

Min-Max

possible from the scale

Min-Max

taken from the scale

Mean±SD

HCAM Total

11

11 – 66

12 - 42

23.05 ± 5.80

Holistic Health Sub-dimension

5

5 – 30

5 - 13

7.36 ± 1.68

CAM Sub-dimension

6

6 – 36

6 - 34

15.69 ± 5.52

HCAM: Holistic Complementary and Alternative Medicine Scale. CAM: Complementary and Alternative Medicine

 

Statistically significant difference was found between the age group of the patients and the mean HCAM total (p=0.028) and holistic health sub-dimension scores (p=0.034); between the education level and the mean CAM sub-dimension score (p=0.048); between the monthly income status and the mean HCAM total (p=0.002) and CAM sub-dimension scores (p=0.002). In addition, the mean HCAMtotal(p=0.038) and the mean holistic health sub-dimension scores (p=0.035) were found to differ in accordance with CAM usage (Table 4).

 

Table 4. Comparison of the patients’ characteristics with their mean score on HCAM Scale

 

Patients’ Characteristics

HCAM

Mean±SD

CAM Sub-dimension

Mean±SD

Holistic Health 

Sub-dimension

Mean±SD

Age

 

50 years old and below a

51-60 years old b

61-70 years old c

70 years old and above d

X2

p

25.92±7.36

22.42±5.26

22.35±5.25

22.77±5.41

9.113*

0.028

a>b,c,d

17.90±6.91

15.35±5.12

15.02±4.99

15.48±5.31

5.304*

0.151

8.02±1.89

7.07±1.75

7.33±1.53

7.30±1.52

8.652*

0.034

a>b,c,d

Gender

 

Female

Male

MWUz

p

22.83±5.95

23.43±5.54

-1.074**

0.283

15.43±5.50

16.13±5.55

-1.159**

0.246

7.40±1.74

7.30±1.57

-0.287**

0.774

Education Level

 

Primary School and Below

High School and above

MWUz

p

22.61±5.38

24.34±6.77

-1.401**

0.161

15.21±5.14

17.11±6.35

-1.975**

0.048

7.41±1.66

7.23±1.75

-1.213**

0.225

Monthly Income

 

Income equals outcome a

Income less than outcome b

Income more than outcome c

X2

p

22.75±5.43

21.81±5.62

25.56±6.33

12.391*

0.002

c>a,b

15.38±4.95

14.49±5.43

18.16±6.37

12.688*

0.002

c>a,b

7.37±1.77

7.32±1.49

7.40±1.71

0.071*

0.965

CAM usage

 

Yes

No

MWUz

p

22.35±5.07

23.97±6.55

-2.079**

0.038

15.19 ±5.04

16.34±6.05

-1.258**

0.208

7.16±1.58

7.63±1.78

-2.113**

0.035

 CAM: Complementary and alternative therapy. HCAMHolistic Complementary and Alternative Medicine Scale

 

Discussion

Hypertension is a health problem that affect primarily the elderly population with increasing incidence and cause the death of millions of individuals every year due to the complications (1). Therefore, in addition to medical treatment, patients tend to use CAM methods that include different practices and ideas. In this study, it was found that most of the patients stated that they knew about the CAM methods used in hypertension. However, the source of information was mostly other individuals who were not health care workers. Similar results have been obtained in studies evaluating the use of CAM in hypertensive patients (7,14) and in different patient groups (18-20) in our country. This can make it more difficult to control the disease by preventing patients to get accurate information from the right sources, and causing patients to acquire unreliable information and to gain negative health behaviors.

In the study, it was found that more than half of the patients (64.8%) believed that CAM methods were beneficial and 56.9% of patients used CAM methods in the treatment of hypertension. All of the patients who used CAM were using herbal methods and used these methods twice a week (43.1%). In studies investigating the use of CAMin hypertensive patients in different countries, Ali-Shtayeh et al. (12) reported 85.7% inPalestine, Ibrahim et al. (21) reported 65.5% in Iraq, Shafiq et al. (22) reported 63.9% in India, Gohar et al. (23) reported 43.1% in the UK, Amira and Okubadejo (24) reported 39.1% in Nigeria. In studies investigating the use of CAM in hypertensive patients in Turkey, Toprak and Demir (25) reported 63.9%, Guven et al. (7) reported 52.7%, while Asilar and Gozum (26) reported 42.7%. Efe et al. (5) reported that 74.8% of the patients used herbal products as the CAM method, while Bahar et al. (14) reported as 51.3%. Adaptation of patients to treatment is very important in achieving blood pressure control and optimum blood pressure values ​​of patients with hypertension (4). The fact that more than half of the patients in this study used CAM and they applied this method twice a week may be considered as an indicator of the lack of blood pressure control and incompliance to the treatment.

It was determined both in this study and in other studies that the herbal products used by hypertension patients were lemon and garlic (5,7,12,14,24). Rohner et al. (27) reported in a meta-analysis study examining the double-blindrandomized controlled studies that garlic may be effective in reducing blood pressure in hypertensive individuals, but the evidence is not strong enough to produce a definite result, and that longer-term, well-planned, stronger studies are needed. It has been reported that garlic is effective on blood pressure without any serious side effects by inhibiting the angiotensin-converting enzyme and showing vasodilatory effect (28). Therefore, hypertension patients may tend to consume such non-pharmacological methods in order to balance their blood pressure. In studies investigating the blood pressure-lowering effect of lemon in hypertensive individuals, Reshef et al. (29) reported that lemon and vitamin C preparations may be effective in patients with mild hypertension, while Sarı et al. (30) found that lemon was frequently used by hypertensive patients, however there was no evidence of a blood pressure lowering effect. It is stated that the lemon will not directly harm the patients with hypertension, but the patients may be harmed especially if they avoid using drugs thereby interfering with the medical treatment.

In the study, patients using CAM were found to use CAM because they thought they were more effective than drugs and that their side effects were less than drugs. Similarly, studies with hypertensive patients have shown that patients prefer using CAM thinking that the side effects of herbal products are less, they are more reliable, they relieve symptoms and because patients are not satisfied with medical treatment (11-13).

In the literature, it is stated that very few patients, such as one in ten people, consulted the physician and nurse about the CAM methods they used (31,32). In this study, it was determined that 63% of the patients did not share the CAM method with the health care workers, and the reason for not sharing was the opinion that they do not need to and that health workers would react / get angry. Similar findings were found in other studies (7,22).

One of the most important factors affecting the use of CAM by patients is the communication problem between the patient and the health team members who are responsible for the patient's holistic care. It is reported that their lack of understanding of fear, anxiety and worries of patients, lack of openness and trust environment, lack of empathy, ineffective listening, and lack of guiding are some of the reasons that direct patients towards the use of CAM. In addition, it is stated that patients prefer to hide this situation from health care personnel because they believe that they will face a negative reaction if they report (33). In a study where Tovey and Broom (34) investigated the approach of health care workers towards CAM ​and the effects on patientsfound that they exhibited three distinct attitudes: some of them showing a distinctly negative attitude, some of them showing a supportive but still contradictory attitude, and some of them being utilitarian and accepting. Due to these different attitudes, it may be thought that patients using CAM may be reluctant to share the methods they use with health workers.

It was determined in the study that the mean HCAM total score was 23.05 ± 5.80, the mean holistic health sub-dimension score was 7.36 ± 1.6, and the mean CAM sub-dimension score was 15.69 ± 5.52. According to the scores obtained from the scale, patients have positive attitudes towards holistic complementary and alternative medicine and use, and it can be said that the perceptionof individuality in their care is very high. In his study, Erci (17) stated that healthy individuals had more negative attitudes towards using CAM than patients. Ibrahim et al. (21) reported in a study with hypertensive patients in Iraq that patients who reported using CAM had more positive attitudes towards CAM ​​than those who did not use them. Using the same scale in Turkey, the attitudes of gynecologicalcancer patients towards CAM was evaluated and the patients were found to have positive attitudes (20). When the literature is examined, it is seen that the studies where attitudes towards CAM are investigated are mostly performed with university students, health care professionals or healthy individuals (17,35,36) and the studies evaluating the attitudes of patients are limited (20-21).

When the mean HCAM and the sub-dimension scores of patients were examined, it was found that patients who acknowledge using CAM had more positive attitudes towards HCAM ​​than the patients who did not, whereas, patients at 50 years of age and below had more negative attitudes towards HCAM compared to the patients who were 50 years and above, and patients with higher income were found to have more negative attitudes towards HCAM ​​than patients with lower income. It was determined that patients with primary and lower education level had more positive attitudes towards CAM ​sub-dimension than patients with high school or higher education level. It has been reported in studies that the positive attitude towards CAM ​​increased with increasing age, and the frequency of use of CAM is higher in patients with low levels of education and income, and the attitudes of CAM-using hypertensive patients and patients with income less than outcome, thoughts about CAM are more positive (7,17, 19,22).

Conclusion

The results of this study showed that patients had positive attitudes towards holistic complementary and alternative medicine, patients used CAM methods in addition to medical treatment but did not share the methods they used with health care workers. The fact that hypertensive patients refer to complementary and alternative therapies may indicate an incompliance to treatment or the methods used may cause undesirable side effects in patients. For this reason, in order to achieve complete blood pressure control, it is necessary for health care workers to question the CAM use of patients and their attitudes towards CAM, to ensure patient participation in organizing the treatment plan and to give importance to patient education.

 

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How to cite / Atıf için: Gokce H, Pasli Gurdogan E. Complementary and alternative therapy usage status and attitudes of hypertension patients. Euras J Fam Med 2019;8(2):59-68. doi:10.33880/ejfm.2019080202


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